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New Preventive Coverage of 21-valent Pneumococcal Vaccine for Medicare Advantage Members (Retroactively effective to June 17, 2024)


Purpose

The purpose of this communication is to provide notice regarding the new preventive coverage criteria for 21-valent pneumococcal vaccine for Medicare Advantage members.  Services covered are retroactively effective to June 17, 2024.

Background

Pneumococcal vaccine provides protection against Streptococcus pneumoniae, which can cause sinusitis, acute otitis media (AOM), bacteremia, meningitis, pneumonia, and death.  Pneumococcal 21-valent conjugate (PCV21) vaccine is purified capsular polysaccharides from S. pneumoniae serotypes 3, 6A, 7F, 8, 9N, 10A, 11A, 12F, 15A, 15B (de-O-acetylated prior to conjugation), 16F, 17F, 19A, 20A, 22F, 23A, 23B, 24F, 31, 33F, and 35B individually conjugated to CRM197 carrier protein.

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On June 17, 2024, PCV21 was approved by the US FDA for the prevention of invasive disease caused by S. pneumoniae serotypes 3, 6A, 7F, 8, 9N, 10A, 11A, 12F, 15A,15B, 15C, 16F, 17F, 19A, 20A, 22F, 23A, 23B, 24F, 31, 33F, and 35B in individuals 18 years of age and older.


Coverage Statement

PCV21 vaccine is covered as a preventive service for individuals 18 years of age and older who currently have a recommendation to receive a dose of PCV.

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EXPERIMENTAL/INVESTIGATIONAL

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PCV21 vaccine is considered experimental/investigational and, therefore, not covered for individuals younger than 18 years of age. 


Coding


90684


08/28/2024